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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602931
Report Date: 10/03/2022
Date Signed: 10/03/2022 11:45:47 AM

Document Has Been Signed on 10/03/2022 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JOSHUA TREE HOMEFACILITY NUMBER:
198602931
ADMINISTRATOR:JASMIN TOMINESFACILITY TYPE:
735
ADDRESS:18207 VILLA CLARA STREETTELEPHONE:
(626) 295-2197
CITY:ROWLAND HEIGHTSSTATE: CAZIP CODE:
91748
CAPACITY: 6CENSUS: 6DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Alvin Capanzana TIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Christine Wong conducted an unannounced annual required visit. LPA met Staff (Administrator in training) Alvin Capanzana and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed clients' medications, observed food supply, and reviewed client and staff files.

The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, kitchen, dining area, Administrator office, staff room, laundry area, four clients bedrooms and two bathrooms and a attached garage. All clients rooms were toured. Bedroom#1 and #4 have two beds, two chairs, dressers, required bed linen and furniture and sufficient lighting and closet space. Bedroom#2 and #3 have one bed, one chair, one night stand, one dresser, required bed linen and furniture and sufficient lighting and closet space. All 2 bathrooms were toured and they are clean, sanitary and in a good working condition. The hot water temperature tested in both bathrooms were between 116.7 and 118.7 and they were within Title 22 regulation. The refrigerator in the kitchen and garage and the kitchen cabinet have sufficient two days perishable and seven days non perishable food supply. All the appliances in the kitchen are clean and working properly. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well. The back yard has a shaded area with table and chairs for client to utilized. LPA also inspected the smoke detectors and carbon monoxide detectors and they are working well.

LPA reviewed all 6 clients emergency contact and they are all updated. LPA also reviewed 2 staff files and they are all finger print cleared and also their health screening forms are updated in their personnel files.
LPA reviewed 6 clients' medications and the medications are centrally stored in a medication cabinet and all clients' medication seemed updated and accurate.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOSHUA TREE HOME
FACILITY NUMBER: 198602931
VISIT DATE: 10/03/2022
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Facility is currently following COVID 19 recommendations regarding COVID 19 signs throughout the facility, the disinfecting products are available in each clients' rooms and common area and facility is disinfected every shift/day. The bathrooms have sufficient soap, paper towels, and signs and the PPE supplies are sufficient for more than 30 days.

No deficiencies were observed during the visit.

Exit Interview conducted and a copy of the report was provided to Alvin Capanzana.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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